The nation's longest-serving HHS secretary speaks bluntly to HealthLeaders about her run for Congress and how the Trump administration should fix healthcare.

Shalala, who headed the department for eight years under former President Bill Clinton and previously served as the president of the University of Miami, is the Democratic nominee campaigning to represent Florida's 27th congressional district.

The polls have her neck-and-neck in a race where healthcare issues, specifically the lack of Medicaid expansion in Florida and the future of the Affordable Care Act, have taken center stage.

Shalala spoke to HealthLeaders about why she's frustrated with the Trump administration's approach to the healthcare system and what she would aim to accomplish if elected to Congress.

Shalala: Well, I decided to run because I was pretty pissed off with what was going on in Washington. [The Trump administration] was basically destroying the healthcare system that we have in this country, undercutting existing programs like Medicare, Medicaid, and the ACA. If you're poor, if you're handicapped, if you're a senior, or if you're a working stiff and don't have access to healthcare, that's a disaster. And increasing the number of people without coverage is a public health disaster for our country.

HL: Are there changes or fixes you would seek to implement to strengthen the ACA?

Shalala: Let me say this, the administration has done everything it could to undercut [the ACA.] It's in court now to try to eliminate the requirements for preexisting conditions. [Republicans in Congress] took away the mandate and unless everybody has insurance, it's difficult to spread the risk. All they're doing is increasing the rest of our insurance costs by increasing the number of people that don't have health insurance.

I think that the administration doesn't care and has done everything it can to increase the number of people who are at risk in this country, and that's immoral.

[One thing] I would do with the ACA, in particular: I never thought that we got the subsidies right at the beginning. Normally, what you do is make tactical corrections after a year, but we were not able to do that. We have to look at the subsidies and the structure—there seems to be a family penalty involved; that is, you can cover the kids but not the spouse. But I think the most important thing is we need to get every state to expand Medicaid because we have millions of people in this country, including here in Florida, who are working every day that have no option in terms of access to affordable healthcare.

HL: So just to be clear, would you be in favor of bringing back the individual mandate that was stripped away in the tax bill last year?

Shalala: Yes, I would be, and I think everybody in healthcare is in favor of that, but you have to make it affordable. A lot of young people didn't take it because they were in the gig economy. That's important to understand, [for most of the] people that didn't take health insurance, it was an affordability issue.

HL: As the nation's longest-serving HHS secretary, what are your thoughts on Secretary Alex Azar's performance in that role? Any advice?

Shalala: I don't think [he's] leading at all. I think [he's] taking orders from the White House. Azar knows better.

But [the Trump administration is] obviously squeezing down on the system, and the number of uninsured is going to increase. For example, they've already eliminated the funds for signing people up for the ACA. They're doing everything they can to keep down the [enrollment] numbers and helping the states to develop cheap healthcare plans. Cheap healthcare plans that don't have to cover preexisting conditions are useless. A lot of people know that but they're scared of the cost of health insurance. It does no good to give people cheap health insurance and make them believe that they have health insurance because when they go to use it, they will not be able to.

In addition to that, they've got this silly idea of letting people buy health insurance across state lines. There are some states that allow that—not one insurance policy has been written, because frankly, if someone from Miami goes up to Georgia and buys a health insurance plan and comes back to Miami and tries to use it, no one's going to take it and then they're going to get mad. They're going to call the health insurance commissioner of Florida, and he's going to say, 'That's not my policy.' Then they're going to call the health commissioner of Georgia, and he's going to say, 'I can't enforce the law outside of Georgia.' So it's a silly idea that will not work.

HL: Is there anything that Congress should do to address the proliferation of association health plans (AHP)?

Shalala: The most important thing is to look at strategies for universal coverage; I think that's the principle. We've got to figure out a way that everybody can get good health insurance. Some of it will be through the government, some of it will be through the private sector, and some of it will be through direct subsidies. But I think the important thing is not the individual strategies, but reaching the goals. I don't like the fragmentation of American healthcare, so filling in the blanks, which is what President Obama tried to do, is very important at this moment. We've got to get everybody good coverage and it has got to be [for] all necessary services.

HL: Would that potentially be through Medicare for All, as some Democrats have proposed?

Shalala: I think that's an expensive way to get universal coverage at this point in time, and I don't think that Medicare is good enough at this point in time. It doesn't have long-term care, it doesn't have dental benefits. And people who have better health insurance than Medicare ought to be able to keep their health insurance.

HL: One of the signature issues the administration has been focusing on is lowering prescription drug prices. What's your opinion of its approach thus far?

Shalala: They've been playing around the edges. Let's see whether they're really willing to take this issue on. Secretary Azar knows better, and so far, what they've done is smoke and mirrors and it hasn't had any impact. So let's see what their new proposals are.

HL: One of the proposals is listing the actual price of prescription drugs on TV ads. What is your opinion of that?

Shalala: It may have marginal effects, but I doubt it because the price won't mean anything to people that have drug coverage. It's symbolic, it doesn't mean anything. I've been opposed from the beginning of advertising on TV. The Clinton administration opposed it, and Congress went ahead and did it over our strongest objections. It's run up the cost of drugs and even [former Senator] Bill Frist, who was Majority Leader at the time, has said it was a mistake.

HL: What should hospital executives and health system leaders take away from your candidacy?

Shalala: That I'm the most knowledgeable candidate on the subject of healthcare that probably has ever been elected. And they know that, they know me, and they know that I'm a reasonable person, and that I'll listen and they've worked with me before.